Contemporary suprasternal transcatheter aortic valve replacement: A multicenter experience using a simple, reliable alternative access approach

Abstract

Objectives To describe outcomes after suprasternal (SS) transcatheter aortic valve replacement (TAVR) as a new alternative access approach. Background There still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. SS‐TAVR is a safe and effective alternative to TF‐TAVR and has now become our preferred alternative access route. Methods We retrospectively reviewed all patients from New York Presbyterian Hospital, Columbia University Medical Center and Princeton Baptist Medical Center who underwent SS‐TAVR from 2015 to July 2018. A total of 84 patients were included in the study. Results Technical success was achieved in all cases. Thirty‐day survival was 98.8% (n = 83). There were minimal complications. Most notably, there were no transient ischemic attacks or strokes (0%, n = 0). Reexploration for bleeding was 3.6% (n = 3), and major bleeding was 1.7% (n = 1). We also achieved satisfactory results with a mean aortic valve gradient of 6.07 ± 3.79 mmHg and an aortic valve area of 2.21 ± 0.51 cm2. No patients had anything more than mild paravalvular leak. The mean length of stay (LOS) in the intensive care unit was 1.42 ± 1.23 days, and hospital LOS was 4.20 ± 3.29 days. Conclusions SS access for TAVR is an extremely important technique to have in any valve team's alternative access armamentarium. This technique can be safely and reliably reproduced with any standard hybrid operating room setup and no additional equipment, and it can be used with any commercially available valve system. In the current experience, minimal complications and excellent early term results were obtained.

Transcatheter Aortic Valve Implantation Access Sites: Same Goals, Distinct Aspects, Various Merits and Demerits

“…Re-exploration was 3.6% (n = 3) for bleeding and 1.7% (n = 1) for major bleeding. The mean length of stay in the intensive care unit was 1.42 ± 1.23 days, and the length of hospitalization was 4.20 ± 3.29 days [97]. Overall, S-B seems to be a feasible and safe approach for TAVI when TF access is not a possible choice.…”

Suprasternal access for transcatheter aortic valve implantation: All ways lead to Rome

“…The quest for the best one is still open and comparative studies are needed, but every heart team must be able to accurately manage more than one non‐TF option in order to tailor treatment to every single patient, although this requires high procedural volumes. Suprasternal approach is quite promising, combining simplicity and safety, and could well represent the first option for non‐TF TAVI in experienced centers, like reported in the article by Eudailey et al 3 …”

“…In this issue, Eudailey et al report the results of the largest series of patients who underwent TAVI through the innominate artery with a suprasternal (SS) access included in a retrospective, 2‐center study 3 . The outcome was excellent, with 100% technical success, 98.8% 30‐day survival, no cerebrovascular accidents and very low incidence of complications overall.…”

“…Every access for TAVI holds relative advantages and disadvantages. Trans‐subclavian was the first non‐TF approach developed after transapical, and in experienced hands it can be well managed percutaneously and without general anesthesia, as well as transcarotid, but a potential drawback for both is the relatively high incidence of stroke 3,4 . Transaortic has the advantage of the easy manipulation and positioning of the THV, but it requires general anesthesia and sternotomy or thoracotomy, according to the patient's anatomy.…”